Nothing to Confess

guidance.

Prologue

In 1999, a report from the Institute of Medicine, entitled To Err Is Human, concluded that as many 98,000 people die annually in the United States as a consequence of medical mistakes. That is equivalent to the death toll that would occur if three jumbo jets crashed every two days. Malpractice claims are filed by only 1.5% of patients harmed by medical errors. This observation suggests either that Americans are not as sue happy as many presume, or that the public remains ignorant about the frequency and severity of medical mistakes. Doctors recognize that there can be a fine line between medical mistakes and expected complications. It is when complications are unexpected that doctors argue with lawyers most vigorously about who is to blame.

Who is to blame when a medical catastrophe happens unexpectedly?

PART I

Chapter One

A Kidney Transplant

May 10, 2008

Mark Hubbard stretched his back and craned his neck to check the digital clock on the wall behind the anesthesiologist. 1:35 AM. Over eight hours in the OR. And I told Mary Ellen I’d be home for dinner. This has been the kidney transplant from hell.

Hubbard turned to the chief resident and the intern who were assisting on the case. Gentlemen, I trust that you can close the fascia and skin? I’m going out to talk to the parents. Make sure to keep his central venous pressure above ten. The last thing this kidney needs is an episode of hypotension.

Got it, Dr. Hubbard. Maintain CVP of ten to fifteen and no blood pressure drops, the chief resident reiterated – mostly for the sake of the yawning intern who would be caring for this patient through the remainder of the night. Turning back to Hubbard before closing the fascia, the chief resident asked, Do you want staples or sutures for the skin?

Staples, and be sure that the skin edges are properly aligned. Let’s at least make the skin closure a successful part of this operation, Mark said sarcastically. It’s the only part of the operation that the patient sees. "Listen, I know you guys only rotate on the Transplant Service a couple months a year, but you gotta understand that a kidney transplant is truly an elective operation, even when we do it in the middle of the night to minimize the organ’s preservation time. People with kidney failure can always be kept alive on dialysis without having a kidney transplant. We do the transplants to improve quality of life and hopefully to prolong the patient’s survival. But these operations are still elective procedures and patients and families expect good outcomes."

The chief resident peered over the top of his mask into the eyes of the intern across the table, rolling his eyes. It’s way too late and I’m way too tired to assimilate these subtle teaching points! Let’s just sew and staple and get the hell out of here! No words were spoken. It was getting near the end of the internship year. The intern completely understood his chief resident’s body and eye language, agreeing with a nod and a long sigh that caused his own surgical mask to bellow.

Mark snapped off his bloody gloves, slipped off his gown, and headed for the waiting area outside of the operating room. Like most surgeons, he dreaded talking to family members about bad outcomes. He was especially upset because he went into the operating room thinking that this kidney transplant would be an easy chip shot. The recipient, Scott Anderson, was eighteen years old and in perfect health, save for kidney failure. He was thin and had an athletic build. The donor was ideal too – a 23- year-old man, also thin and muscular, dying from a massive cocaine overdose complicated by a stroke. He had no significant past medical history and his kidney function was perfect when brain death was declared. An ideal recipient and an ideal donor. This operation should have been a chip shot.

Mark mentally prepared his thoughts as he strolled toward the waiting area. Nothing beyond the standard of care. Just an unusual but expected complication. That all sounded like language doctors used when dealing with malpractice lawyers. But Mark realized that surgical complications, expected or unexpected, were difficult for troubled family members to digest. Use lay terminology with these parents and be honest. This wasn’t the first time he had to do this, and it wouldn’t be the last.

Earlier in the day – before the transplant operation – Mark met with Scott’s mother, Sarah Anderson, to get a quick update on her son’s recent health status and to discuss details about the surgery and the anticipated postoperative care. Sarah seemed almost too calm. Mark got an immediate feeling that she had been through more strenuous medical ordeals in her lifetime.

To test his hunch, he asked Do you have a medical background?

Oh not really, except for dealing with our sick kids. You see, when Ken and I got married twenty-three years ago, we agreed that we wanted only two children. Scott was our second son. I had a tubal ligation shortly after his birth. Scott’s older brother, Sam, developed a brain tumor at the age of sixteen – it was a medulloblastoma in the base of his brain. She glanced up to Hubbard to be sure he understood. He nodded to indicate that he was at least a little familiar with brain tumors.

Sam died nine months later after lots of radiation therapy and multiple surgical procedures, Sarah went on. We live west of Lima in a small town called St. Marys. It’s between the Ohio- Indiana border and Wapakoneta – you know, home of Neil Armstrong, first man on the moon? So, during Sam’s ordeal, Ken and I spent the larger part of a year traveling back and forth here to the Ohio Medical Center for his medical care. Ninety-six point five miles each way to be exact. I hate to admit it, Doctor, but we know this place pretty well…too well.

Mark immediately felt sorry for the Anderson family and wanted to be upbeat. Listen, Mrs. Anderson, Scott’s donor was in ideal shape, and this new kidney should work even better and longer than most kidney transplants from deceased donors, he offered. Sarah was very thankful and appreciative.

Now, as he approached the OR waiting area almost half a day later, Mark spotted Sarah with a tall heavy-set man, presumably her husband. He was pacing the floor and appeared worried. Jesus, I should have tempered my pre-transplant enthusiasm. The husband was wearing a crumpled white shirt with rolled up sleeves, an open collar, and an unassembled blue necktie flying at half-mast. Sarah was wearing the same yellow sun dress she wore earlier in the day. She appeared concerned but less flustered than her husband.

Hi. I’m Mark Hubbard. You must be Mr. Anderson, said Mark, extending his weary right arm to shake hands with Scott’s father.

Hi, yes, Ken Anderson here. Ken was trying to be strong but couldn’t keep his voice from shaking. He had been pacing the floor for hours, imagining that he would be bold and harsh with a long list of demanding questions for Scott’s surgeon. However, when the confrontation materialized, he melted as he always did when dealing with someone whose professional stature was greater than his own.

He tried to calm down. I think you met my wife, Sarah, earlier today, he said, almost whispering. What’s going on, Doctor? A nurse came out of the operating room at around 10 PM and said you were having trouble with the blood vessels. Sarah said the operation would take three hours. Is Scott OK? Its way beyond three hours – it’s been more like eight. We’re worried sick.

Scott’s going to be fine, Hubbard replied. "But yes, we had problems with the arterial anastamosis – the connection between the donor artery and Scott’s iliac artery. As part of the routine in preparing a kidney for transplantation, we work with the organ on a back table in the operating room, literally cleaning off the kidney, dissecting fatty tissue from its surface. The surgeon who removed this kidney reported that there was a single artery feeding the organ – that’s the usual anatomy in eighty per cent of cases. When we took the organ to the back table, we discovered that there was a small second renal artery that went unnoticed by the procuring surgeon. It was hidden in the fatty tissue. Again, this is not unusual." Am I being defensive?

"The procuring surgeons work very methodically to extract the organs from the donor. In this case, the donor ’s family agreed to allow all organs to be harvested – not just the two kidneys, but also the liver, the pancreas, two lungs, and the heart. When there are several teams of surgeons removing organs in sequence, it’s easy for the kidney surgeon to miss an extra renal artery, especially if it’s small." Yes, I AM being defensive!

Mark looked at the Andersons and realized they were only following his story loosely, waiting for a punch line.

Anyhow, the first arterial connection with the main artery went smoothly. But the second artery was too short for me to create an anastamosis directly to Scott’s iliac artery. So we needed to remove a vein from his left groin to use as a jump graft between Scott’s internal iliac artery and the shortened artery from the allograft. You’ll notice that he has two incisions – one on his lower right abdomen, and another on his left upper thigh where we obtained the vein graft.

Seeing complete confusion on the faces of the anxious parents, Mark found some paper and a pencil at a nearby receptionist desk and proceeded to draw pictures to explain the complicated anastamosis.

What does all of this mean? asked Sarah.

"The extra time spent doing the second arterial anastamosis means that at least part of the kidney was subjected to some warm ischemia – a lack of blood flow. That’s different than the cold ischemia that occurs when the organ is preserved in iced solutions."

So, is the kidney working or not? asked Ken Anderson, getting a bit agitated once again, and still not fully compre- hending Hubbard’s technical explanation about the arterial problem.

The last step of the kidney transplant surgery consists of sewing the ureter of the new kidney into the recipient’s bladder after the blood vessels have been hooked up. When the kidney works right away, urine flows freely through the new ureter, literally pissing like a racehorse over the whole operative field before we get the end of the ureter sewn into the bladder, Mark said with a smile, but finding no return smiles from Ken or Sarah. I guess neither of them has ever seen a racehorse pissing.

He stifled his smile and went on. "Scott’s new kidney wasn’t making any urine at the end of the case, so it’s not working right now. But you have to keep in mind that about twenty-five percent of kidney transplants from deceased donors don’t function immediately. We call it ‘delayed graft function’ – basically the kidney goes into a state of shock. The organ will recover in over ninety-five percent of cases, but the recovery process can take anywhere from days to weeks. This is probably not a good time to tell them that it can actually take up to three months. During that period of ‘shock’, patients usually need to continue on dialysis treatments. We’ll consult our Nephrology Service and they’ll follow Scott closely to decide whether he will need dialysis on a day-to-day basis."

So, sounds like it’s just ‘wait and see’ for now? offered Sarah.

In all honesty, I am very concerned about the small second renal artery. It’s possible that the portion of the kidney supplied by that artery may be infarcted or dead. As we were finishing the case, the upper pole of the kidney pinked up some, but the lower pole looked dusky and blue. We’ll do a Doppler ultrasound scan first thing in the morning and that should give us the answer. If there’s an infarction, my hope is that it involves only a small portion of the kidney. If so, it is likely that the remaining normal part of the kidney will provide enough function to get Scott off of dialysis eventually.

Sounds like a lot of hoping, but I guess we’ll hope along with you, said Ken. Hey, Doc, Scott is scheduled to graduate from high school in a couple of weeks – do you think he’ll make it? We’d love to see him walk up that aisle and get his diploma.

We’ll see. I hope so, Mark responded, intentionally overusing the word ‘hope.’ He could tell that the Andersons were tired and disappointed. So was he. The warm ischemia time mandated by the arterial reconstruction was almost thirty-five minutes, and he was worried about the viability of the entire transplanted kidney. But he was being totally honest with Sarah and Ken. He always tried to be completely honest with patients and families. And there was room to be optimistic in this case because both the recipient and donor were young. There was room for hope.

Scott will be transferred to the Recovery Room shortly but he probably won’t wake up from the anesthesia for another few hours, said Mark. I’m heading home to catch a few hours of sleep and will be back at 7:30 for morning rounds. I suggest you do the same.

Dr. Hubbard, as I mentioned earlier, we live more than an hour and a half away, west of here – so we’d actually prefer to stay until the morning, said Sarah. Maybe we can catch a few winks on the couches here.

That’s fine. The ICU staff can give you some pillows and blankets. Unless you have any other questions, I’ll see you in the morning.

Ken and Sarah could not sleep. They were each terrified by the possibility that Scott’s kidney transplant would not work and that he would require dialysis treatments forever. They also were concerned that this simple kidney transplant could turn into a prolonged hospitalization. After tossing and turning for an hour, Sarah broke the silence. Ken, I’m beginning to see those ninety- six point five miles all over again.

The couple was fitfully dozing off on the waiting room couches when an ICU nurse interrupted their broken sleep at 5 AM. She spoke quietly, trying not to disturb another group of visitors that were soundly sleeping in the opposite corner of the room. Hi, I’m Jane Pollack. Your son Scott has been moved from Recovery to the ICU next door. I’ll be his nurse today. His post- op blood work showed a potassium of 7.2. A dialysis nurse is on her way to perform an urgent dialysis treatment. We called Dr. Hubbard and he agrees with doing the dialysis. Scott is waking up, and you are welcome to join him if you’d like.

Okay, Jane, thanks. I thought the potassium level was normally around 4. Did you say it was 7.2? asked Sarah, now very familiar with language of kidney failure, dialysis, and related blood test results.

Yeah, 7.2 is pretty elevated and it can cause cardiac arrhythmias. The good news is that his EKG is normal, but he’ll still need dialysis urgently to get the potassium down. Sorry for waking you folks up, but I thought you’d want to know what’s going on. Honestly, this is all pretty routine after a new kidney transplant, said Jane, pausing as she recognized that the Andersons seemed a little anxious. She smiled and tried to reassure them that the high potassium level was nothing to worry about, now sitting down to help Sarah and Ken feel more comfortable. So tell me about Scott’s kidney problems.

Sarah looked at Jane and realized they were each about the same age. I’m sure this nice woman has family stories of her own. Somehow, Sarah always felt a sense of relief when she was able to divulge her life story to a sympathetic ear. She proceeded to tell Jane about her first son, Sam, and his fatal brain tumor.

About a year after Sam died, Scott developed the nephrotic syndrome. The look on Jane’s face indicated that she was only vaguely familiar with the terminology.

Sarah went on. "It’s a kidney disorder resulting from loss of protein in the urine. It leads to massive swelling of the extrem- ities and the face. After all those trips with Sam, Ken and I once again had to travel frequently here to the OMC for treatment of Scott’s kidney problem. The clinics and hospitals in Lima said his condition was too rare for them to handle. Scott had a kidney biopsy and it showed a disease called focal and segmental glomerulosclerosis – FSGS for short. For six months, he was treated with prednisone – pretty high doses – but it didn’t help. Funny thing is, when Scott initially discovered that prednisone was a ‘steroid’ he was expecting to beef up his biceps and quads…you know, Schwarzenegger style. But we all quickly learned that prednisone is a catabolic steroid, not one of those anabolic steroids that some athletes use to build muscle mass."

I’ve seen lots of patients who are taking high doses of prednisone, Jane interjected. The side effects can be really nasty.

Exactly, Sarah responded. Scott developed a fat swollen face. He had mood swings – sometimes he seemed irritable and depressed, at other times almost overly energetic. He got terrible acne on his face, and on his back and chest. He had bouts of raging indigestion and needed to take all sorts of antacids and other stomach remedies. You know, Scott was looking like a first- rate running back on the varsity football team, but he had to quit sports during his sophomore year because the kidney disease caused such bad swelling of his legs. He could hardly walk, let alone run.

Sarah was getting teary-eyed and Jane quickly disappeared and reappeared with a box of tissues before encouraging Sarah to continue her story.

Anyhow, after six months of prednisone, Scott’s pediatric nephrologist met with me and Ken to inform us that Scott was developing irreversible kidney failure. He would need either dialysis or a kidney transplant. He wasn’t responding to prednisone, despite all of the side effects. And there was no other treatment. She told us that a kidney transplant was the best option, but quickly tempered her optimism by pointing out that there was a chance – somewhere between thirty and fifty percent – that the FSGS would recur in a newly transplanted kidney, possibly destroying it. It seemed in medicine that good news was always accompanied by some bad news.

Jane remained attentive, and Sarah continued. Ken was ruled out as a kidney donor to Scott because he had diabetes. He’s been taking diabetic pills and following a diabetic diet for more than eight years now. I couldn’t donate to Scott because I have an incompatible blood type. I’m type A and he is type B. And of course there are no other siblings to serve as living family donors.

Sarah went on, after pausing to grab another tissue. Scott was placed on the waiting list for a kidney transplant from a deceased donor. We were told that it would take between three and five years before he would be called in for a transplant – owing to the large number of patients on the waiting list ahead of him. We’ve been living through a nightmare of teenage illnesses for over five years.

So this kidney transplant is really good news for you two! Jane offered, now becoming conscious of the time and her need to back to the ICU.

Sarah peered into Jane’s eyes and said, You know, Scott is our only remaining child. When we received the call about the kidney that had become available for Scott several hours ago, it seemed like a nightmare had finally come to an end. But then…this bit of bad news from Dr. Hubbard about a problem with the kidney’s arterial connection.

Ken had been following Sarah’s review of the Anderson family story and finally chimed in. To think I was worried that the original disease might recur in the transplanted kidney, Ken said to Sarah and Jane. "That was my big concern – waiting to see if his FSSG, or whatever it’s called, would recur in his new kidney. Now it sounds like the kidney might not work at all."

Ken, that’s not what Dr. Hubbard said,’ Sarah retorted. I thought he said there was a ninety-five percent chance it would work. And it’s called ‘FSGS’."

He was talking about statistics, not this individual case with the faulty artery. That artery problem changes everything. Just our luck. Just Scott’s luck. Oh, what the hell, let’s just keep our fingers crossed and hope that the scan is okay this morning.

Good idea, said Jane, offering to